Most of us would expect to feel at our best first thing in the morning - refreshed and ready for a new day. Yet many people find the opposite, suffering from health complaints that tend to be worse as dawn breaks.

Here, experts identify the illnesses that are at their worst first thing - and what you can do to reduce the symptoms.

COUGHS

Irritation caused by acid reflux is a common cause of early morning cough. Lying down while you sleep allows acid to travel up from the stomach into the oesophagus and upper airways. The irritation triggers a powerful urge to cough.

One in five who takes high blood pressure medication such as Ramipril develops a dry cough

'It can help to avoid large meals late at night, keeping an evening meal light,' says Dr Louise Selby, a GP based in Surrey. This is because food in the stomach puts pressure on the sphincter valve at the bottom of the oesophagus.

If you suffer from chronic morning coughing, see your doctor, as long-term acid reflux can be a sign that the valve isn't working properly - this can eventually lead to pre-cancerous changes in cells lining the oesophagus.

Certain medications can trigger an early morning cough. For example, one person in five who takes a form of high blood pressure medication known as an ACE inhibitor, such as Ramipril, develops a dry cough.

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One theory is that the drug stops the breakdown of a protein called bradykinin, which can make the coughing reflex more sensitive. The cough may develop several months after you start taking the medication, says Dr Selby. If you stop taking it, the cough should disappear within two months, but first discuss alternative treatments with your doctor, she advises.

Smokers are prone to a morning cough, as the cilia - the fine, hair-like structures in the airways that normally remove mucus and harmful particles - become damaged, and during sleep these particles collect in the lungs, so when the smoker wakes up their cough reflex is triggered.

Other causes of a morning cough include a post-nasal drip, when mucus collects in the throat as a result of colds, flu, allergies or even pregnancy.

Wear and tear

Many of us think arthritis is inevitable with age. We reveal the surprising triggers. This week: wellies.

They
may be great for sloshing about in the mud, but wearing wellies too
often could cause you to develop arthritis, experts suggest.

A
Swedish study found that osteoarthritis of the hip was common in farmers
and labourers. This was linked to carrying heavy loads - but wellies
could be part of the problem, too, says Martin Bell, a clinical
orthotist from Bristol.

'Cheap rubber boots can be a disaster for
feet,' he says. 'They are usually loose fitting on the ankle, allowing
feet to move around inside. 'This causes an unnatural stress to the
patellofemoral joint (the knee joint). With footwear that offers no
support, you can be fooled into thinking your feet are protected. But
boots cause you to lose muscle control, so muscles can't help the toes
and ankles, and in turn the hips, to support the body.

'This
triggers osteoarthritis - as each joint overcompensates for the weakened
ones, the body begins building extra bone mass to compensate.'

Bony growths that develop around the edges of joints are a characteristic of osteoarthritis, leading to pain and stiffness.

HELEN WRIGHT

An allergy to house dust mites - found in mattresses, bedding and carpets - can also trigger a morning cough, as this causes a build-up of excess mucus in the night, leading to sometimes violent coughing on waking. As well as trying to reduce the dust in your home, nasal sprays such as beconase, a steroid that decreases inflammation in the nasal passages, can help.

Asthma may cause a persistent morning cough, particularly in the winter, when changes of temperature and humidity exacerbate symptoms. 'With regular treatment, usually including preventative inhalers, it should be possible to control these symptoms,' says Dr Selby.

GOUT

Around 800,000 people in Britain suffer from gout. It occurs when uric acid - created by the breakdown of substances called purines, found in certain food and drink - forms needle-like crystals that settle in the joints, leading to pain and swelling.

Studies show that a gout attack is most likely to occur late at night or in the early morning. 'It may be that the inflammatory process gets worse during the night when the joints are colder,' says Chris Deighton, a consultant rheumatologist at the Royal Derby Hospital and president of the British Society for Rheumatology. 'This might encourage crystal development.'

Levels of cortisol, a natural anti-inflammatory, tend to be lowest just before dawn, which may also exacerbate morning symptoms.

To help prevent a morning attack, have a glass of water before sleep and keep a glass of water by the bed. 'People who are dehydrated are more prone to gout,' explains Dr Deighton.

This is probably because dehydration increases the concentration of uric acid in the blood, making it more likely to form crystals in the joints. Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce pain and inflammation. The main long-term treatment is a diet low in purines, and drugs that lower uric acid levels.

IRRITABLE BOWEL SYNDROME

This gut disorder affects around a third of the population at some point in their lives, causing a range of symptoms including stomach cramps, bloating, constipation and diarrhoea. The so-called 'morning rush' - acute diarrhoea when you wake - is a common problem.

Researchers at the University of North Carolina's Centre for Functional GI and Motility Disorders have found that people with IBS often have higher levels of the hormone cortisol in the morning than healthy people, which may somehow make symptoms worsen.

The 'morning rush' can be eased in some cases by avoiding alcohol and fizzy drinks at night. A low-fat diet and reduced intake of caffeine may also help.

Some people with IBS find fatty foods exacerbate their stomach problems, while caffeine is a stimulant that causes contractions of the gastrointestinal tract.

HEADACHE

People with chronic obstructive pulmonary disease often complain of headaches

Half of migraines start in the morning - and other headaches, including tension headaches, often wake people from sleep, according to Migraine Action.

Several factors could be responsible. One is that between 4am and 8am, levels of natural painkillers called endorphins and enkephalins are at their lowest.

At the same time, adrenaline, which regulates the contraction of blood vessels, is released in larger quantities and may help to bring on migraines, which are linked to constricted blood supply. Furthermore, wakefulness is influenced by an area of the brain known as the brain stem, which is also known to be involved in initiating migraines.

Hypnic headaches - which occur exclusively at night, waking you from sleep at the same time, usually between 1am and 3am -are nicknamed 'alarm clock headaches'. 'They can be eased by taking caffeine before bedtime,' says Dr Andy Dowson, director of headache services at King's College Hospital, London.

People with chronic obstructive pulmonary disease (a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease) often complain of headaches that are worst in the morning.

'That's because they are not breathing deeply enough at night, causing carbon dioxide to build up and oxygen levels to fall,' says Dr Dowson.

It can help to lie propped up on cushions - or place a block under the bedposts at the head of the bed to take some pressure off the chest and ease breathing.

People suffering from depression often wake up with feelings of gloom and anxiety

DEPRESSION

People suffering from depression often wake up with feelings of gloom and anxiety that are worst in the morning and lift as the day progresses.

'It is recognised that there can be a dramatic variation in mood depending on the time of the day,' says Jim Bolton, a consultant psychiatrist and spokesman for the Royal College of Psychiatrists.

One theory is that this is linked to levels of cortisol, which should start to rise in the morning and give us a feeling of 'get up and go'. Those with depression may not have this surge and instead their cortisol levels flatline.

'It might help people with depression if they stick to routines to help their body find its natural rhythm again,' says Dr Bolton. 'Staying in bed is not a good idea because it just causes more disruption to the body's natural cycle.'

SORE THROAT

All sore throats, whether they are caused by a virus or a bacterial infection, tend to be worst first thing in the morning.

'In most cases it is because the throat has got too dry overnight, drying out the delicate mucosa that lines the mouth and airways,' says Dr Selby. This can affect even people who have no health problems.

'A sore throat can be caused by hot, dry air in the bedroom. It can also be caused by having a blocked nose and having to mouth-breathe, which dries the mouth further.

'Turning the heat down at night can be helpful, as well as placing a humidifier in the bedroom. Adding extra moisture to the air is one of the best ways to combat morning throat problems.'

Otherwise, try decongestants including menthol rubs on the chest. Inhaling steam from a bowl of hot salt water can also help to clear mucus.

Smoking, and certain medical conditions such as sleep apnoea (chronic snoring triggered when the tissues in the airways collapse during sleep), can also cause a sore throat on waking in the morning because they dry it out.

Sometimes just sipping a glass of water or juice can help by lubricating the throat. The Mayo Clinic, in the U.S., recommends stirring some honey into hot water to ease a morning throat.

Honey acts as a mild decongestant and helps to remove excess mucus. Acid reflux can also cause a sore throat in the morning (see Coughing, on previous page).

TINNITUS

THIS condition causes an unexplained ringing in the ears and affects one person in ten in Britain at some point.

Many sufferers complain that the ringing they hear is at its worst first thing in the morning. Research from the University of Leicester suggests that uncontrolled activity in the brain's cells (neurons) could be one of the causes of tinnitus.

A spokesman for the British Tinnitus Association explains: 'When we wake in the morning our brain activity is quite high.

'As we get moving and more alert, it drops. Given that tinnitus is linked with brain activity, it follows that higher activity (on just waking) may result in louder tinnitus.'

Another possible reason for the early-morning peak is that lying in a quiet room with no other distractions means the ringing sound may seem louder.

The condition can be managed with distraction techniques - for instance, using products to mask the sound. Patients may also be offered tinnitus retraining therapy, which is based on the idea that the nervous system can be trained to disregard the noise.

BACK PAIN

People with osteoarthritis in the spine often find that in the morning their backache is debilitating

One person in three experiences back and neck pain after a night's sleep, according to a recent study of 2,400 people for the British Chiropractic Association. In most cases the pain is caused by poor posture or sleeping on a mattress that is too soft.

'Investing in a more supportive mattress can make a huge difference,' says Dr Christine Haseler, a GP with a specialist interest in orthopaedic medicine.

'A mattress that is too soft allows the spine to slump and doesn't support it in an anatomically correct position.'

There are also some specific medical conditions that cause morning backache.

People with osteoarthritis in the spine often find that in the morning their backache is so debilitating it can take them hours to become fully mobile and pain-free.

This is due to a build-up of inflammatory chemicals in the joints as you lie still at night, says Dr Haseler - during the day moving about gets the blood and fluids circulating, so the inflammatory agents are washed out.

Moving the affected joint repeatedly on waking should help to ease stiffness.

MORNING SICKNESS

Despite the name, this does not occur only in the morning -although most women find it worst at that time of day.

Nausea in pregnancy is caused by surges of HCG - human chorionic gonadotropin hormone - which is made by cells that form the placenta.

HCG is normally excreted in the urine; during sleep it builds up, peaking in the morning. To help, get up slowly and avoid drinking anything on an empty stomach, as this makes vomiting more likely.

Mike Bowen, a London-based consultant obstetrician and gynaecologist, says some medications can be safely taken to ease severe sickness: 'A number of antiemetics (anti-sickness medications) are effective and safe to use in pregnancy.

'Many are prescription-only, but several can be purchased over the counter, including Pepto-Bismol.'Otherwise, ginger, taken as fresh root in tea, capsules or even as good-quality ginger biscuits, in moderation is known to ease nausea.'

A lack of vitamin B6 in the diet may make morning sickness worse - one theory is that it helps the body metabolise certain amino acids (the building blocks of protein). A deficiency means these amino acids are not broken down effectively, leading to worse morning sickness.

Jargon Buster

Medical terms decoded. This week: Cardiac arrest

Very
simply, a cardiac arrest is when the heart stops pumping. It is often
confused with a heart attack (myocardial infarction - where heart tissue
dies because it isn't getting enough blood) - this can lead to cardiac
arrest, but not always.

Cardiac arrest can be triggered by a heart
condition, choking, electric shocks or losing a lot of blood. These all
disrupt blood supply, leading to ventrical fibrillation, where the heart
quivers rather than pumps.

A cardiac arrest is also different from
heart failure. Heart failure does not mean that the heart stops
completely - instead it struggles to pump blood efficiently. This is
usually because it is not emptying itself of blood properly, and in turn
not taking in enough oxygenated blood.Someone who has gone into
cardiac arrest will lose consciousness and have no pulse.

It is
life-threatening and requires CPR (cardiopulmonary resuscitation) and
defibrillation - CPR keeps blood and oxygen moving around the body,
while defibrillators use electric shocks to get the heart pumping again.
Heart attack, however, is usually treated with drugs to dissolve clots
and restore blood flow to the heart, or surgery to widen the coronary
artery, known as angioplasty.

JENNIE AGG

STROKE

Studies show that you are more likely to have an ischaemic stroke - the most common type of stroke, which happens when a clot lodges in a blood vessel in the brain - between 6am and noon. This may be because platelets, the tiny cells that help the blood to clot, are stickier at this time of day, so they are more likely to form a clot inside a blood vessel, explains Joe Korner, director of external affairs at the charity Stroke Association.

'Fluctuation of blood pressure is also another risk factor,' he says. 'When you get up, your blood pressure soars from low to quite high and this rapid rise may play a part.'

As high blood pressure remains the single biggest risk factor for stroke, he recommends having your blood pressure checked at least once a year.

You can also reduce stroke risk by not smoking and keeping to a healthy weight.

FIBROMYALGIA

This condition affects just under a million people in Britain, triggering pain and tenderness all over the body.

What causes it is not known, although it has been linked to changes in brain chemicals and oversensitivity in the nerves.

Patients often complain of pain and stiffness first thing in the morning, which can last for hours. This may be due to a variety of factors such as the muscles stiffening during sleep and the fact that levels of cortisol, which helps to reduce inflammation, drop during the night.

'It might be that cortisol is needed to keep muscles pain-free,' says Dr Austin Leach, a consultant in pain medicine at the Royal Liverpool Hospitals Trust and spokesman for the British Pain Society.

'Bed rest is the worst thing you can do. Get up and get moving - even if it hurts,' says Dr Leach.